Dr. Nancy Scolieri - Family Dentistry
Patient Screening Form
4101 Rutherford Rd, #1, Woodbridge, ON L4L 0K1
905-264-2322
Patient Name:
Patient Age:
E-mail:
Date
Temperature Check In Office - ℃
Screening Questions
Pre-Screen
In-Office
Yes
No
Yes
No
Q1:
Are you immunocompromised and/or live in a highest-risk congregate care setting?
Q2:
Do you have any of the following symptons:
Fever
New Onset of Cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult > 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
If child < 18 years of age: nausea/vomiting, diarrhea
Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
Q4:
Did you travel outside of Canada in the past 14 days?
Q5:
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
I verify all of this information to be accurate and true.
Signature
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